Karen Radtke
HW215 Models for Health and Wellness
Unit 7 Assignment: Cultural Competence
January 14, 2015

Cultural Needs Patient Questionnaire

1. Are there any specific practices or restrictions I should know about in providing your medical care? (e.g. dietary restrictions, use of blood products).” www.aafp.org/afp/2001/0101/p81.html.

2. For some people, their religion or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs, is this true for you? www.aafp.org/afp/2001/0101/p81.html.

3. Are you worried about any conflicts between your beliefs and your medical situation/care/decisions? www.aafp.org/afp/2001/0101/p81.html.

4. What resources can I provide to you that can help you make the decisions you need to make about your medical needs that will go towards your beliefs?

5. What internal support do you have in your life at this current time that can help you make the decisions that you will need you make during this time?

6. In order to ensure that you understand what is going on during our discussions about your medical condition, is there a certain language that you more comfortable with other than English? www.mhcs.com

7. Would you like an interpreter to be present when we discuss your medical condition which could be a family member, friend or a health care associate?

8. When making decisions about the care you receive do you want your family involved in the decision making process and if so, which family member do you want involved?

9. Is there any type of food that you are accustomed to due to your religious beliefs, or family traditions that we need to be aware of in order to make sure that we are able to provide you with the food